|
FLU VAC TS 2024(6 MOS UP)C.DER.(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE [185931]
|
Facility
|
IP
|
$125.94
|
|
|
Service Code
|
HCPCS 90661
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.96 |
| Max. Negotiated Rate |
$125.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.90
|
| Rate for Payer: Altius Commercial |
$120.90
|
| Rate for Payer: Beech Street Commercial |
$123.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$103.40
|
| Rate for Payer: Cash Price |
$88.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$122.16
|
| Rate for Payer: Cigna of WY Commercial |
$123.42
|
| Rate for Payer: Entrust Commercial |
$119.64
|
| Rate for Payer: First Choice Health Commercial |
$119.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$83.12
|
| Rate for Payer: HealthUtah PPO |
$125.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$122.16
|
| Rate for Payer: Multiplan Medicare/VA |
$78.96
|
| Rate for Payer: One Health Plan of WY PPO |
$123.42
|
| Rate for Payer: PacificSource Commercial |
$113.35
|
| Rate for Payer: PHCS PPO |
$123.42
|
| Rate for Payer: Three Rivers PPO |
$94.46
|
| Rate for Payer: TriWest Veterans Administration |
$83.12
|
| Rate for Payer: United Healthcare Commercial |
$109.57
|
| Rate for Payer: United Healthcare Medicare |
$83.12
|
| Rate for Payer: WINHealth Partners Commercial |
$119.64
|
| Rate for Payer: Wise Provider Network Commercial |
$119.64
|
|
|
FLU VAC TS 2024(6 MOS UP)C.DER.(PF) 45 MCG(15 MCGX3)/0.5 ML IM SYRINGE [185931]
|
Facility
|
OP
|
$125.94
|
|
|
Service Code
|
HCPCS 90661
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.39 |
| Max. Negotiated Rate |
$125.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$123.42
|
| Rate for Payer: Aetna of WY Medicare |
$83.12
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.90
|
| Rate for Payer: Altius Commercial |
$120.90
|
| Rate for Payer: Beech Street Commercial |
$123.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$103.40
|
| Rate for Payer: Cash Price |
$88.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$122.16
|
| Rate for Payer: Cigna of WY Commercial |
$123.42
|
| Rate for Payer: Entrust Commercial |
$119.64
|
| Rate for Payer: First Choice Health Commercial |
$119.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$119.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.05
|
| Rate for Payer: HealthUtah PPO |
$125.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$122.16
|
| Rate for Payer: Multiplan Medicare/VA |
$69.39
|
| Rate for Payer: One Health Plan of WY PPO |
$123.42
|
| Rate for Payer: PacificSource Commercial |
$113.35
|
| Rate for Payer: PHCS PPO |
$123.42
|
| Rate for Payer: Three Rivers PPO |
$94.46
|
| Rate for Payer: TriWest Veterans Administration |
$73.05
|
| Rate for Payer: United Healthcare Commercial |
$109.57
|
| Rate for Payer: United Healthcare Medicare |
$73.05
|
| Rate for Payer: WINHealth Partners Commercial |
$123.42
|
| Rate for Payer: Wise Provider Network Commercial |
$119.64
|
|
|
FLUVIRIN VACC, 3 YRS & >, IM
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS Q2037
|
| Hospital Charge Code |
Q2037
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$32.19
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
FLUZONE VACC, 3 YRS & >, IM
|
Professional
|
Both
|
$30.00
|
|
|
Service Code
|
HCPCS Q2038
|
| Hospital Charge Code |
Q2038
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.40
|
| Rate for Payer: Beech Street Commercial |
$28.50
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: Cash Price |
$21.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.10
|
| Rate for Payer: Cigna of WY Commercial |
$29.40
|
| Rate for Payer: First Choice Health Commercial |
$27.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.50
|
| Rate for Payer: HealthUtah PPO |
$30.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.10
|
| Rate for Payer: One Health Plan of WY PPO |
$29.40
|
| Rate for Payer: PacificSource Commercial |
$27.00
|
| Rate for Payer: PHCS PPO |
$28.50
|
| Rate for Payer: Three Rivers PPO |
$22.50
|
| Rate for Payer: TriWest Veterans Administration |
$20.00
|
| Rate for Payer: United Healthcare Commercial |
$26.10
|
| Rate for Payer: WINHealth Partners Commercial |
$28.50
|
|
|
FOLEY TRAY LATEX BAG A300316A
|
Facility
|
OP
|
$46.86
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.82 |
| Max. Negotiated Rate |
$46.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$45.92
|
| Rate for Payer: Aetna of WY Medicare |
$30.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$44.99
|
| Rate for Payer: Altius Commercial |
$44.99
|
| Rate for Payer: Beech Street Commercial |
$45.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.47
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.45
|
| Rate for Payer: Cigna of WY Commercial |
$45.92
|
| Rate for Payer: Entrust Commercial |
$44.52
|
| Rate for Payer: First Choice Health Commercial |
$44.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.18
|
| Rate for Payer: HealthUtah PPO |
$46.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.45
|
| Rate for Payer: Multiplan Medicare/VA |
$25.82
|
| Rate for Payer: One Health Plan of WY PPO |
$45.92
|
| Rate for Payer: PacificSource Commercial |
$42.17
|
| Rate for Payer: PHCS PPO |
$45.92
|
| Rate for Payer: Three Rivers PPO |
$35.14
|
| Rate for Payer: TriWest Veterans Administration |
$27.18
|
| Rate for Payer: United Healthcare Commercial |
$40.77
|
| Rate for Payer: United Healthcare Medicare |
$27.18
|
| Rate for Payer: WINHealth Partners Commercial |
$45.92
|
| Rate for Payer: Wise Provider Network Commercial |
$44.52
|
|
|
FOLEY TRAY LATEX BAG A300316A
|
Facility
|
IP
|
$46.86
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$29.38 |
| Max. Negotiated Rate |
$46.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$45.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$44.99
|
| Rate for Payer: Altius Commercial |
$44.99
|
| Rate for Payer: Beech Street Commercial |
$45.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$38.47
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.45
|
| Rate for Payer: Cigna of WY Commercial |
$45.92
|
| Rate for Payer: Entrust Commercial |
$44.52
|
| Rate for Payer: First Choice Health Commercial |
$44.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.93
|
| Rate for Payer: HealthUtah PPO |
$46.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.45
|
| Rate for Payer: Multiplan Medicare/VA |
$29.38
|
| Rate for Payer: One Health Plan of WY PPO |
$45.92
|
| Rate for Payer: PacificSource Commercial |
$42.17
|
| Rate for Payer: PHCS PPO |
$45.92
|
| Rate for Payer: Three Rivers PPO |
$35.14
|
| Rate for Payer: TriWest Veterans Administration |
$30.93
|
| Rate for Payer: United Healthcare Commercial |
$40.77
|
| Rate for Payer: United Healthcare Medicare |
$30.93
|
| Rate for Payer: WINHealth Partners Commercial |
$44.52
|
| Rate for Payer: Wise Provider Network Commercial |
$44.52
|
|
|
FOLEY TRAY LATEX M&T A319416AM
|
Facility
|
IP
|
$90.11
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.50 |
| Max. Negotiated Rate |
$90.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$88.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$86.51
|
| Rate for Payer: Altius Commercial |
$86.51
|
| Rate for Payer: Beech Street Commercial |
$88.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$73.98
|
| Rate for Payer: Cash Price |
$63.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$87.41
|
| Rate for Payer: Cigna of WY Commercial |
$88.31
|
| Rate for Payer: Entrust Commercial |
$85.60
|
| Rate for Payer: First Choice Health Commercial |
$85.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$85.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.47
|
| Rate for Payer: HealthUtah PPO |
$90.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$87.41
|
| Rate for Payer: Multiplan Medicare/VA |
$56.50
|
| Rate for Payer: One Health Plan of WY PPO |
$88.31
|
| Rate for Payer: PacificSource Commercial |
$81.10
|
| Rate for Payer: PHCS PPO |
$88.31
|
| Rate for Payer: Three Rivers PPO |
$67.58
|
| Rate for Payer: TriWest Veterans Administration |
$59.47
|
| Rate for Payer: United Healthcare Commercial |
$78.40
|
| Rate for Payer: United Healthcare Medicare |
$59.47
|
| Rate for Payer: WINHealth Partners Commercial |
$85.60
|
| Rate for Payer: Wise Provider Network Commercial |
$85.60
|
|
|
FOLEY TRAY LATEX M&T A319416AM
|
Facility
|
OP
|
$90.11
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.65 |
| Max. Negotiated Rate |
$90.11 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$88.31
|
| Rate for Payer: Aetna of WY Medicare |
$59.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$86.51
|
| Rate for Payer: Altius Commercial |
$86.51
|
| Rate for Payer: Beech Street Commercial |
$88.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$73.98
|
| Rate for Payer: Cash Price |
$63.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$87.41
|
| Rate for Payer: Cigna of WY Commercial |
$88.31
|
| Rate for Payer: Entrust Commercial |
$85.60
|
| Rate for Payer: First Choice Health Commercial |
$85.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$85.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.26
|
| Rate for Payer: HealthUtah PPO |
$90.11
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$87.41
|
| Rate for Payer: Multiplan Medicare/VA |
$49.65
|
| Rate for Payer: One Health Plan of WY PPO |
$88.31
|
| Rate for Payer: PacificSource Commercial |
$81.10
|
| Rate for Payer: PHCS PPO |
$88.31
|
| Rate for Payer: Three Rivers PPO |
$67.58
|
| Rate for Payer: TriWest Veterans Administration |
$52.26
|
| Rate for Payer: United Healthcare Commercial |
$78.40
|
| Rate for Payer: United Healthcare Medicare |
$52.26
|
| Rate for Payer: WINHealth Partners Commercial |
$88.31
|
| Rate for Payer: Wise Provider Network Commercial |
$85.60
|
|
|
FOLEY TRAY LATEX UM A303316A
|
Facility
|
OP
|
$60.78
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$33.49 |
| Max. Negotiated Rate |
$60.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$59.56
|
| Rate for Payer: Aetna of WY Medicare |
$40.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$58.35
|
| Rate for Payer: Altius Commercial |
$58.35
|
| Rate for Payer: Beech Street Commercial |
$59.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.90
|
| Rate for Payer: Cash Price |
$42.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.96
|
| Rate for Payer: Cigna of WY Commercial |
$59.56
|
| Rate for Payer: Entrust Commercial |
$57.74
|
| Rate for Payer: First Choice Health Commercial |
$57.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.25
|
| Rate for Payer: HealthUtah PPO |
$60.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.96
|
| Rate for Payer: Multiplan Medicare/VA |
$33.49
|
| Rate for Payer: One Health Plan of WY PPO |
$59.56
|
| Rate for Payer: PacificSource Commercial |
$54.70
|
| Rate for Payer: PHCS PPO |
$59.56
|
| Rate for Payer: Three Rivers PPO |
$45.58
|
| Rate for Payer: TriWest Veterans Administration |
$35.25
|
| Rate for Payer: United Healthcare Commercial |
$52.88
|
| Rate for Payer: United Healthcare Medicare |
$35.25
|
| Rate for Payer: WINHealth Partners Commercial |
$59.56
|
| Rate for Payer: Wise Provider Network Commercial |
$57.74
|
|
|
FOLEY TRAY LATEX UM A303316A
|
Facility
|
IP
|
$60.78
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.11 |
| Max. Negotiated Rate |
$60.78 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$59.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$58.35
|
| Rate for Payer: Altius Commercial |
$58.35
|
| Rate for Payer: Beech Street Commercial |
$59.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$49.90
|
| Rate for Payer: Cash Price |
$42.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$58.96
|
| Rate for Payer: Cigna of WY Commercial |
$59.56
|
| Rate for Payer: Entrust Commercial |
$57.74
|
| Rate for Payer: First Choice Health Commercial |
$57.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$57.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.11
|
| Rate for Payer: HealthUtah PPO |
$60.78
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$58.96
|
| Rate for Payer: Multiplan Medicare/VA |
$38.11
|
| Rate for Payer: One Health Plan of WY PPO |
$59.56
|
| Rate for Payer: PacificSource Commercial |
$54.70
|
| Rate for Payer: PHCS PPO |
$59.56
|
| Rate for Payer: Three Rivers PPO |
$45.58
|
| Rate for Payer: TriWest Veterans Administration |
$40.11
|
| Rate for Payer: United Healthcare Commercial |
$52.88
|
| Rate for Payer: United Healthcare Medicare |
$40.11
|
| Rate for Payer: WINHealth Partners Commercial |
$57.74
|
| Rate for Payer: Wise Provider Network Commercial |
$57.74
|
|
|
FOLEY TRAY SILICONE
|
Facility
|
OP
|
$97.87
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$53.93 |
| Max. Negotiated Rate |
$97.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.91
|
| Rate for Payer: Aetna of WY Medicare |
$64.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$93.96
|
| Rate for Payer: Altius Commercial |
$93.96
|
| Rate for Payer: Beech Street Commercial |
$95.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$80.35
|
| Rate for Payer: Cash Price |
$68.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.93
|
| Rate for Payer: Cigna of WY Commercial |
$95.91
|
| Rate for Payer: Entrust Commercial |
$92.98
|
| Rate for Payer: First Choice Health Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.76
|
| Rate for Payer: HealthUtah PPO |
$97.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.93
|
| Rate for Payer: Multiplan Medicare/VA |
$53.93
|
| Rate for Payer: One Health Plan of WY PPO |
$95.91
|
| Rate for Payer: PacificSource Commercial |
$88.08
|
| Rate for Payer: PHCS PPO |
$95.91
|
| Rate for Payer: Three Rivers PPO |
$73.40
|
| Rate for Payer: TriWest Veterans Administration |
$56.76
|
| Rate for Payer: United Healthcare Commercial |
$85.15
|
| Rate for Payer: United Healthcare Medicare |
$56.76
|
| Rate for Payer: WINHealth Partners Commercial |
$95.91
|
| Rate for Payer: Wise Provider Network Commercial |
$92.98
|
|
|
FOLEY TRAY SILICONE
|
Facility
|
IP
|
$97.87
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.36 |
| Max. Negotiated Rate |
$97.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.91
|
| Rate for Payer: Altius Auto/Workers Compensation |
$93.96
|
| Rate for Payer: Altius Commercial |
$93.96
|
| Rate for Payer: Beech Street Commercial |
$95.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$80.35
|
| Rate for Payer: Cash Price |
$68.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.93
|
| Rate for Payer: Cigna of WY Commercial |
$95.91
|
| Rate for Payer: Entrust Commercial |
$92.98
|
| Rate for Payer: First Choice Health Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.59
|
| Rate for Payer: HealthUtah PPO |
$97.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.93
|
| Rate for Payer: Multiplan Medicare/VA |
$61.36
|
| Rate for Payer: One Health Plan of WY PPO |
$95.91
|
| Rate for Payer: PacificSource Commercial |
$88.08
|
| Rate for Payer: PHCS PPO |
$95.91
|
| Rate for Payer: Three Rivers PPO |
$73.40
|
| Rate for Payer: TriWest Veterans Administration |
$64.59
|
| Rate for Payer: United Healthcare Commercial |
$85.15
|
| Rate for Payer: United Healthcare Medicare |
$64.59
|
| Rate for Payer: WINHealth Partners Commercial |
$92.98
|
| Rate for Payer: Wise Provider Network Commercial |
$92.98
|
|
|
FOLIC ACID 1 MG TABLET [15881]
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 6068768111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.52
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.79
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
FOLIC ACID 1 MG TABLET [15881]
|
Facility
|
OP
|
$0.83
|
|
|
Service Code
|
NDC 6068768111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.83 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.81
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.80
|
| Rate for Payer: Altius Commercial |
$0.80
|
| Rate for Payer: Beech Street Commercial |
$0.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.81
|
| Rate for Payer: Entrust Commercial |
$0.79
|
| Rate for Payer: First Choice Health Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.48
|
| Rate for Payer: HealthUtah PPO |
$0.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.81
|
| Rate for Payer: PacificSource Commercial |
$0.75
|
| Rate for Payer: PHCS PPO |
$0.81
|
| Rate for Payer: Three Rivers PPO |
$0.62
|
| Rate for Payer: TriWest Veterans Administration |
$0.48
|
| Rate for Payer: United Healthcare Commercial |
$0.72
|
| Rate for Payer: United Healthcare Medicare |
$0.48
|
| Rate for Payer: WINHealth Partners Commercial |
$0.81
|
| Rate for Payer: Wise Provider Network Commercial |
$0.79
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [9367]
|
Facility
|
IP
|
$34.62
|
|
|
Service Code
|
NDC 6332318410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.71 |
| Max. Negotiated Rate |
$34.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.93
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.24
|
| Rate for Payer: Altius Commercial |
$33.24
|
| Rate for Payer: Beech Street Commercial |
$33.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.42
|
| Rate for Payer: Cash Price |
$24.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.58
|
| Rate for Payer: Cigna of WY Commercial |
$33.93
|
| Rate for Payer: Entrust Commercial |
$32.89
|
| Rate for Payer: First Choice Health Commercial |
$32.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.85
|
| Rate for Payer: HealthUtah PPO |
$34.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.58
|
| Rate for Payer: Multiplan Medicare/VA |
$21.71
|
| Rate for Payer: One Health Plan of WY PPO |
$33.93
|
| Rate for Payer: PacificSource Commercial |
$31.16
|
| Rate for Payer: PHCS PPO |
$33.93
|
| Rate for Payer: Three Rivers PPO |
$25.96
|
| Rate for Payer: TriWest Veterans Administration |
$22.85
|
| Rate for Payer: United Healthcare Commercial |
$30.12
|
| Rate for Payer: United Healthcare Medicare |
$22.85
|
| Rate for Payer: WINHealth Partners Commercial |
$32.89
|
| Rate for Payer: Wise Provider Network Commercial |
$32.89
|
|
|
FOLIC ACID 5 MG/ML INJECTION SOLUTION [9367]
|
Facility
|
OP
|
$34.62
|
|
|
Service Code
|
NDC 6332318410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.08 |
| Max. Negotiated Rate |
$34.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.93
|
| Rate for Payer: Aetna of WY Medicare |
$22.85
|
| Rate for Payer: Altius Auto/Workers Compensation |
$33.24
|
| Rate for Payer: Altius Commercial |
$33.24
|
| Rate for Payer: Beech Street Commercial |
$33.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.42
|
| Rate for Payer: Cash Price |
$24.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.58
|
| Rate for Payer: Cigna of WY Commercial |
$33.93
|
| Rate for Payer: Entrust Commercial |
$32.89
|
| Rate for Payer: First Choice Health Commercial |
$32.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.08
|
| Rate for Payer: HealthUtah PPO |
$34.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.58
|
| Rate for Payer: Multiplan Medicare/VA |
$19.08
|
| Rate for Payer: One Health Plan of WY PPO |
$33.93
|
| Rate for Payer: PacificSource Commercial |
$31.16
|
| Rate for Payer: PHCS PPO |
$33.93
|
| Rate for Payer: Three Rivers PPO |
$25.96
|
| Rate for Payer: TriWest Veterans Administration |
$20.08
|
| Rate for Payer: United Healthcare Commercial |
$30.12
|
| Rate for Payer: United Healthcare Medicare |
$20.08
|
| Rate for Payer: WINHealth Partners Commercial |
$33.93
|
| Rate for Payer: Wise Provider Network Commercial |
$32.89
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [11540]
|
Facility
|
OP
|
$1,169.41
|
|
|
Service Code
|
HCPCS J1451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$644.34 |
| Max. Negotiated Rate |
$1,169.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,146.02
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$994.70
|
| Rate for Payer: Aetna of WY Medicare |
$771.81
|
| Rate for Payer: Aetna of WY Medicare |
$669.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$974.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,122.63
|
| Rate for Payer: Altius Commercial |
$1,122.63
|
| Rate for Payer: Altius Commercial |
$974.40
|
| Rate for Payer: Beech Street Commercial |
$994.70
|
| Rate for Payer: Beech Street Commercial |
$1,146.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$960.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$833.32
|
| Rate for Payer: Cash Price |
$710.50
|
| Rate for Payer: Cash Price |
$818.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,134.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$984.55
|
| Rate for Payer: Cigna of WY Commercial |
$994.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,146.02
|
| Rate for Payer: Entrust Commercial |
$1,110.94
|
| Rate for Payer: Entrust Commercial |
$964.25
|
| Rate for Payer: First Choice Health Commercial |
$964.25
|
| Rate for Payer: First Choice Health Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$964.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$678.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$588.70
|
| Rate for Payer: HealthUtah PPO |
$1,015.00
|
| Rate for Payer: HealthUtah PPO |
$1,169.41
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$984.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,134.33
|
| Rate for Payer: Multiplan Medicare/VA |
$644.34
|
| Rate for Payer: Multiplan Medicare/VA |
$559.26
|
| Rate for Payer: One Health Plan of WY PPO |
$994.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1,146.02
|
| Rate for Payer: PacificSource Commercial |
$1,052.47
|
| Rate for Payer: PacificSource Commercial |
$913.50
|
| Rate for Payer: PHCS PPO |
$994.70
|
| Rate for Payer: PHCS PPO |
$1,146.02
|
| Rate for Payer: Three Rivers PPO |
$761.25
|
| Rate for Payer: Three Rivers PPO |
$877.06
|
| Rate for Payer: TriWest Veterans Administration |
$678.26
|
| Rate for Payer: TriWest Veterans Administration |
$588.70
|
| Rate for Payer: United Healthcare Commercial |
$883.05
|
| Rate for Payer: United Healthcare Commercial |
$1,017.39
|
| Rate for Payer: United Healthcare Medicare |
$678.26
|
| Rate for Payer: United Healthcare Medicare |
$588.70
|
| Rate for Payer: WINHealth Partners Commercial |
$994.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,146.02
|
| Rate for Payer: Wise Provider Network Commercial |
$964.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,110.94
|
|
|
FOMEPIZOLE 1 GRAM/ML INTRAVENOUS SOLUTION [11540]
|
Facility
|
IP
|
$1,169.41
|
|
|
Service Code
|
HCPCS J1451
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$733.22 |
| Max. Negotiated Rate |
$1,169.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,146.02
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$994.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,122.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$974.40
|
| Rate for Payer: Altius Commercial |
$974.40
|
| Rate for Payer: Altius Commercial |
$1,122.63
|
| Rate for Payer: Beech Street Commercial |
$1,146.02
|
| Rate for Payer: Beech Street Commercial |
$994.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$833.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$960.09
|
| Rate for Payer: Cash Price |
$818.58
|
| Rate for Payer: Cash Price |
$710.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$984.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,134.33
|
| Rate for Payer: Cigna of WY Commercial |
$1,146.02
|
| Rate for Payer: Cigna of WY Commercial |
$994.70
|
| Rate for Payer: Entrust Commercial |
$964.25
|
| Rate for Payer: Entrust Commercial |
$1,110.94
|
| Rate for Payer: First Choice Health Commercial |
$964.25
|
| Rate for Payer: First Choice Health Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$964.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,110.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$771.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$669.90
|
| Rate for Payer: HealthUtah PPO |
$1,169.41
|
| Rate for Payer: HealthUtah PPO |
$1,015.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$984.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,134.33
|
| Rate for Payer: Multiplan Medicare/VA |
$733.22
|
| Rate for Payer: Multiplan Medicare/VA |
$636.40
|
| Rate for Payer: One Health Plan of WY PPO |
$1,146.02
|
| Rate for Payer: One Health Plan of WY PPO |
$994.70
|
| Rate for Payer: PacificSource Commercial |
$1,052.47
|
| Rate for Payer: PacificSource Commercial |
$913.50
|
| Rate for Payer: PHCS PPO |
$994.70
|
| Rate for Payer: PHCS PPO |
$1,146.02
|
| Rate for Payer: Three Rivers PPO |
$761.25
|
| Rate for Payer: Three Rivers PPO |
$877.06
|
| Rate for Payer: TriWest Veterans Administration |
$771.81
|
| Rate for Payer: TriWest Veterans Administration |
$669.90
|
| Rate for Payer: United Healthcare Commercial |
$883.05
|
| Rate for Payer: United Healthcare Commercial |
$1,017.39
|
| Rate for Payer: United Healthcare Medicare |
$771.81
|
| Rate for Payer: United Healthcare Medicare |
$669.90
|
| Rate for Payer: WINHealth Partners Commercial |
$964.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,110.94
|
| Rate for Payer: Wise Provider Network Commercial |
$964.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,110.94
|
|
|
FO NONTORSION JOINT CF
|
Professional
|
Both
|
$329.00
|
|
|
Service Code
|
HCPCS L3935
|
| Hospital Charge Code |
L3935
|
| Min. Negotiated Rate |
$246.75 |
| Max. Negotiated Rate |
$329.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$322.42
|
| Rate for Payer: Beech Street Commercial |
$312.55
|
| Rate for Payer: Cash Price |
$230.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$319.13
|
| Rate for Payer: Cigna of WY Commercial |
$322.42
|
| Rate for Payer: First Choice Health Commercial |
$296.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$312.55
|
| Rate for Payer: HealthUtah PPO |
$329.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$319.13
|
| Rate for Payer: One Health Plan of WY PPO |
$322.42
|
| Rate for Payer: PacificSource Commercial |
$296.10
|
| Rate for Payer: PHCS PPO |
$312.55
|
| Rate for Payer: Three Rivers PPO |
$246.75
|
| Rate for Payer: United Healthcare Commercial |
$286.23
|
| Rate for Payer: WINHealth Partners Commercial |
$312.55
|
|
|
FOOT PLAS HEEL STABI PRE OTS
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
HCPCS L3170
|
| Hospital Charge Code |
L3170
|
| Min. Negotiated Rate |
$72.75 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.06
|
| Rate for Payer: Beech Street Commercial |
$92.15
|
| Rate for Payer: Cash Price |
$67.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.09
|
| Rate for Payer: Cigna of WY Commercial |
$95.06
|
| Rate for Payer: First Choice Health Commercial |
$87.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.15
|
| Rate for Payer: HealthUtah PPO |
$97.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.09
|
| Rate for Payer: One Health Plan of WY PPO |
$95.06
|
| Rate for Payer: PacificSource Commercial |
$87.30
|
| Rate for Payer: PHCS PPO |
$92.15
|
| Rate for Payer: Three Rivers PPO |
$72.75
|
| Rate for Payer: United Healthcare Commercial |
$84.39
|
| Rate for Payer: WINHealth Partners Commercial |
$92.15
|
|
|
FO PIP DIP JNT/SPRNG PRE OTS
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS L3925
|
| Hospital Charge Code |
L3925
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.14
|
| Rate for Payer: Beech Street Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.71
|
| Rate for Payer: Cigna of WY Commercial |
$42.14
|
| Rate for Payer: First Choice Health Commercial |
$38.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$40.85
|
| Rate for Payer: HealthUtah PPO |
$43.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.71
|
| Rate for Payer: One Health Plan of WY PPO |
$42.14
|
| Rate for Payer: PacificSource Commercial |
$38.70
|
| Rate for Payer: PHCS PPO |
$40.85
|
| Rate for Payer: Three Rivers PPO |
$32.25
|
| Rate for Payer: United Healthcare Commercial |
$37.41
|
| Rate for Payer: WINHealth Partners Commercial |
$40.85
|
|
|
FORCEPS GRASPING ROTATABLE
|
Facility
|
OP
|
$581.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$320.13 |
| Max. Negotiated Rate |
$581.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$569.38
|
| Rate for Payer: Aetna of WY Medicare |
$383.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$557.76
|
| Rate for Payer: Altius Commercial |
$557.76
|
| Rate for Payer: Beech Street Commercial |
$569.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$477.00
|
| Rate for Payer: Cash Price |
$406.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$563.57
|
| Rate for Payer: Cigna of WY Commercial |
$569.38
|
| Rate for Payer: Entrust Commercial |
$551.95
|
| Rate for Payer: First Choice Health Commercial |
$551.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$551.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$336.98
|
| Rate for Payer: HealthUtah PPO |
$581.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$563.57
|
| Rate for Payer: Multiplan Medicare/VA |
$320.13
|
| Rate for Payer: One Health Plan of WY PPO |
$569.38
|
| Rate for Payer: PacificSource Commercial |
$522.90
|
| Rate for Payer: PHCS PPO |
$569.38
|
| Rate for Payer: Three Rivers PPO |
$435.75
|
| Rate for Payer: TriWest Veterans Administration |
$336.98
|
| Rate for Payer: United Healthcare Commercial |
$505.47
|
| Rate for Payer: United Healthcare Medicare |
$336.98
|
| Rate for Payer: WINHealth Partners Commercial |
$569.38
|
| Rate for Payer: Wise Provider Network Commercial |
$551.95
|
|
|
FORCEPS GRASPING ROTATABLE
|
Facility
|
IP
|
$581.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$364.29 |
| Max. Negotiated Rate |
$581.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$569.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$557.76
|
| Rate for Payer: Altius Commercial |
$557.76
|
| Rate for Payer: Beech Street Commercial |
$569.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$477.00
|
| Rate for Payer: Cash Price |
$406.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$563.57
|
| Rate for Payer: Cigna of WY Commercial |
$569.38
|
| Rate for Payer: Entrust Commercial |
$551.95
|
| Rate for Payer: First Choice Health Commercial |
$551.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$551.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$383.46
|
| Rate for Payer: HealthUtah PPO |
$581.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$563.57
|
| Rate for Payer: Multiplan Medicare/VA |
$364.29
|
| Rate for Payer: One Health Plan of WY PPO |
$569.38
|
| Rate for Payer: PacificSource Commercial |
$522.90
|
| Rate for Payer: PHCS PPO |
$569.38
|
| Rate for Payer: Three Rivers PPO |
$435.75
|
| Rate for Payer: TriWest Veterans Administration |
$383.46
|
| Rate for Payer: United Healthcare Commercial |
$505.47
|
| Rate for Payer: United Healthcare Medicare |
$383.46
|
| Rate for Payer: WINHealth Partners Commercial |
$551.95
|
| Rate for Payer: Wise Provider Network Commercial |
$551.95
|
|
|
FORESKN MANJ W/LSS PREPUTIAL ADS&STRETCHING
|
Professional
|
Both
|
$289.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
54450
|
| Min. Negotiated Rate |
$46.02 |
| Max. Negotiated Rate |
$289.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$283.22
|
| Rate for Payer: Aetna of WY Medicare |
$54.14
|
| Rate for Payer: Beech Street Commercial |
$274.55
|
| Rate for Payer: Cash Price |
$202.30
|
| Rate for Payer: Cash Price |
$202.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$280.33
|
| Rate for Payer: Cigna of WY Commercial |
$283.22
|
| Rate for Payer: First Choice Health Commercial |
$260.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$274.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.14
|
| Rate for Payer: HealthUtah PPO |
$289.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$280.33
|
| Rate for Payer: Multiplan Medicare/VA |
$46.02
|
| Rate for Payer: One Health Plan of WY PPO |
$283.22
|
| Rate for Payer: PacificSource Commercial |
$260.10
|
| Rate for Payer: PHCS PPO |
$274.55
|
| Rate for Payer: Three Rivers PPO |
$216.75
|
| Rate for Payer: TriWest Veterans Administration |
$54.14
|
| Rate for Payer: United Healthcare Commercial |
$251.43
|
| Rate for Payer: United Healthcare Medicare |
$54.14
|
| Rate for Payer: WINHealth Partners Commercial |
$245.65
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [91002]
|
Facility
|
IP
|
$158.82
|
|
|
Service Code
|
HCPCS J1453
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.58 |
| Max. Negotiated Rate |
$158.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$155.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$69.58
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$63.70
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$126.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$152.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$62.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$68.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$123.60
|
| Rate for Payer: Altius Commercial |
$152.47
|
| Rate for Payer: Altius Commercial |
$68.16
|
| Rate for Payer: Altius Commercial |
$123.60
|
| Rate for Payer: Altius Commercial |
$62.40
|
| Rate for Payer: Beech Street Commercial |
$69.58
|
| Rate for Payer: Beech Street Commercial |
$63.70
|
| Rate for Payer: Beech Street Commercial |
$155.64
|
| Rate for Payer: Beech Street Commercial |
$126.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$105.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$130.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$58.29
|
| Rate for Payer: Cash Price |
$90.12
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$111.17
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$154.06
|
| Rate for Payer: ChoiceCare Network Commercial |
$124.89
|
| Rate for Payer: ChoiceCare Network Commercial |
$63.05
|
| Rate for Payer: ChoiceCare Network Commercial |
$68.87
|
| Rate for Payer: Cigna of WY Commercial |
$69.58
|
| Rate for Payer: Cigna of WY Commercial |
$126.18
|
| Rate for Payer: Cigna of WY Commercial |
$63.70
|
| Rate for Payer: Cigna of WY Commercial |
$155.64
|
| Rate for Payer: Entrust Commercial |
$61.75
|
| Rate for Payer: Entrust Commercial |
$67.45
|
| Rate for Payer: Entrust Commercial |
$122.31
|
| Rate for Payer: Entrust Commercial |
$150.88
|
| Rate for Payer: First Choice Health Commercial |
$150.88
|
| Rate for Payer: First Choice Health Commercial |
$122.31
|
| Rate for Payer: First Choice Health Commercial |
$67.45
|
| Rate for Payer: First Choice Health Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$150.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$122.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$67.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$84.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$104.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.86
|
| Rate for Payer: HealthUtah PPO |
$128.75
|
| Rate for Payer: HealthUtah PPO |
$158.82
|
| Rate for Payer: HealthUtah PPO |
$71.00
|
| Rate for Payer: HealthUtah PPO |
$65.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$68.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$124.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$154.06
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$63.05
|
| Rate for Payer: Multiplan Medicare/VA |
$80.73
|
| Rate for Payer: Multiplan Medicare/VA |
$40.76
|
| Rate for Payer: Multiplan Medicare/VA |
$44.52
|
| Rate for Payer: Multiplan Medicare/VA |
$99.58
|
| Rate for Payer: One Health Plan of WY PPO |
$63.70
|
| Rate for Payer: One Health Plan of WY PPO |
$155.64
|
| Rate for Payer: One Health Plan of WY PPO |
$126.18
|
| Rate for Payer: One Health Plan of WY PPO |
$69.58
|
| Rate for Payer: PacificSource Commercial |
$58.50
|
| Rate for Payer: PacificSource Commercial |
$115.88
|
| Rate for Payer: PacificSource Commercial |
$142.94
|
| Rate for Payer: PacificSource Commercial |
$63.90
|
| Rate for Payer: PHCS PPO |
$69.58
|
| Rate for Payer: PHCS PPO |
$63.70
|
| Rate for Payer: PHCS PPO |
$126.18
|
| Rate for Payer: PHCS PPO |
$155.64
|
| Rate for Payer: Three Rivers PPO |
$119.12
|
| Rate for Payer: Three Rivers PPO |
$53.25
|
| Rate for Payer: Three Rivers PPO |
$48.75
|
| Rate for Payer: Three Rivers PPO |
$96.56
|
| Rate for Payer: TriWest Veterans Administration |
$42.90
|
| Rate for Payer: TriWest Veterans Administration |
$84.98
|
| Rate for Payer: TriWest Veterans Administration |
$104.82
|
| Rate for Payer: TriWest Veterans Administration |
$46.86
|
| Rate for Payer: United Healthcare Commercial |
$61.77
|
| Rate for Payer: United Healthcare Commercial |
$56.55
|
| Rate for Payer: United Healthcare Commercial |
$138.17
|
| Rate for Payer: United Healthcare Commercial |
$112.01
|
| Rate for Payer: United Healthcare Medicare |
$84.98
|
| Rate for Payer: United Healthcare Medicare |
$46.86
|
| Rate for Payer: United Healthcare Medicare |
$42.90
|
| Rate for Payer: United Healthcare Medicare |
$104.82
|
| Rate for Payer: WINHealth Partners Commercial |
$150.88
|
| Rate for Payer: WINHealth Partners Commercial |
$122.31
|
| Rate for Payer: WINHealth Partners Commercial |
$67.45
|
| Rate for Payer: WINHealth Partners Commercial |
$61.75
|
| Rate for Payer: Wise Provider Network Commercial |
$61.75
|
| Rate for Payer: Wise Provider Network Commercial |
$150.88
|
| Rate for Payer: Wise Provider Network Commercial |
$122.31
|
| Rate for Payer: Wise Provider Network Commercial |
$67.45
|
|
